Cardiovascular Flashcards
When are pacemakers used?
To stimulate a patient’s heart when they are experiencing bradycardia and HR cannot be improved by drugs (ie - Atropine)
Most often used to treat symptomatic bradycardia
What are the two types of temporary pacemakers?
What is the difference?
When are they used?
Transcutaneous - emergency situations, short term, use pacer pads
Transvenous - pacer wires placed in RV (lose atrial kick), can be left in x1 week
Used for bradycardic arrhythmias (heart blocks)
What are the four types of permanent pacemakers?
Single - atrial or ventricular
Dual - atrial and ventricular
CRT - dilated cardiomyopathy
ICD - life-threatening arrhythmias (can pace and defibrillate as needed)
When is atrial pacing indicated?
SA node dysfunction, but normal AV conduction
When is ventricular pacing indicated?
Damaged ventricular response
What is CRT used for?
Dilated cardiomyopathy - improve CO
When is epicardial pacing used?
Major cardio/thoracic surgeries in case of post-op arrhythmias
Demand pacing
Non-demand pacing
Rate responsive pacing
Fires only when needed (HR falls below predetermined rate)
Fires at a predetermined rate whether it is needed or not
Will speed up or slow down depending on the patient’s level of activity
Fire
Capture
Sense
Pacemaker sent an impulse
Impulse resulted in contraction
Pacemaker can detect pt’s own beats
- High # = higher fence = low sensitivity (wont’s sense pt’s electrical activity)
- Low # = lower fence = high sensitivity (will sense too much of pt’s electrical activity
Under-sensing
Sensitivity set too low (high fence)
Cannot sense patient’s own electrical activity
Can cause lethal rhythms (R on T phenomenon)
Over-sensing
Sensitivity set too high (low fence)
Senses too much of the patient’s own electrical activity
Ie - may sense pt movement and not fire sensing it as cardiac activity
What to do if a permanent PM fails to fire?
Call MD STAT
Call for PM Magnet
Prep for TCP
Call EP team to assess PM fx
Loss of capture
Pacer spikes do not result in complex - not enough energy to cause depolarization
CAD: Progressive ___________ disorder of the coronary arteries that result in ________ or complete ________
CAD: Progressive ATHEROSCLEROTIC disorder of the coronary arteries that result in NARROWING or complete OCCULUSION
Atherosclerosis: ______ builds up in arteries, blocking blood flow. Caused by accumulation of _____, _____, and waste products. Mature ______ can crack/rupture resulting in ________ ________
Atherosclerosis: PLAQUE builds up in arteries, blocking blood flow. Caused by accumulation of CHOLESTEROL, FATS, and waste products. Mature PLAQUE can crack/rupture resulting in CLOT FORMATION
ACS is the _______ of atherosclerosis
It includes:
ACS is the MANIFESTATION of atherosclerosis
It includes: stable angina, unstable angina, NSTEMI, STEMI
Angina
Lack of oxygen to heart muscle which leads to chest pain, discomfort, and pressure
Typical Chest Pain
Heavy chest pressure and/or pain/heaviness
Radiates to neck, jaw, shoulder, arms, back
SOB
Nausea
Sweating
Light-headedness
Atypical Chest Pain
Who does it often affect?
Pleuritic pain
Abdominal pain
Radiates to lower ext
Often affects women, elderly, diabetic individuals
Stable Angina: ________ and ______ by similar precipitating factors
Typically _______ induced and lasts less than ___ mins and relieved by _____
Is it detected by ECG/cardiac biomarkers?
Treatment: AABCO
Stable Angina: PREDICTABLE and REPRODUCIBLE by similar precipitating factors
Typically EXERTION induced and lasts less than 5 mins and relieved by REST
Is it detected by ECG/cardiac biomarkers? - NO
Treatment: AABCO
- Aspirin
- ACE inhibitor
- BB
- Clopidogrel
- Oral nitrates
Unstable Angina: ______ chest pain that occurs at ____ and gets worse
Not relieved by _______ or ________
Unstable Angina: UNPREDICTABLE chest pain that occurs at REST and gets worse
Not relieved by medication or rest
All new CP or change in frequency is considered _______ and should be treated as a potential MI until more information is gathered
All new CP or change in frequency is considered UNSTABLE and should be treated as a potential MI until more information is gathered
Irreversible myocardial necrosis that results from abrupt decrease or total blockage of blood flow to cardiac tissue
Two types
MI
NSTEMI
STEMI
NSTEMI: ______ occlusion of CA
May or may not be ________
May see _______ ________ on ECG
Confirmed by _________ __________
NSTEMI: PARTIAL occlusion of CA
May or may not be SYMPTOMATIC
May see ST DEPRESSION on ECG
Confirmed by CARDIAC BIOMARKERS
Unstable Angina vs NSTEMI
Treatment is the ________
Goal is to ______ ________
Difference is the presence of ______ ________
NSTEMI has ischemia severe enough to cause ______ ________ which causes the release of ________ ________
Unstable Angina vs NSTEMI
Treatment is the SAME
Goal is to PREVENT PROGRESSION
Difference is the presence of CARDIAC BIOMARKERS
NSTEMI has ischemia severe enough to cause MYOCARDIAL INJURY which causes the release of CARDIAC BIOMARKERS
TROP VS CK
________ is more sensitive and specific to myocardial damage
Measured at _______ and q ______hrs until levels have peaked
If a patient has a 2nd episode of CP, it is easier to recognize with _____ as they come back to baseline quicker
_______ only stays elevated for 1-2 _____ wherease _____ stays elevated for 1-2 ____
TROP VS CK
TROP is more sensitive and specific to myocardial damage
Measured at PRESENTATION and q 3-6 until levels have peaked
If a patient has a 2nd episode of CP, it is easier to recognize with CK as they come back to baseline quicker
CK only stays elevated for 1-2 DAYS whereas TROP stays elevated for 1-2 WEEKS
Treatment for Unstable Angina/NSTEMI
Nitro: ____mg SL/spray - ___ doses max in ___ mins __ mins apart
Ask if they have taken ________
Contraindicated in patient with _________ MI
Morphine: When pain not relieved after ______
O2: For sats <_____ or ________
ASA: Given on ______ and continued; ______mg _____
BB: Reduced myocardial _____
CCB: Decreases ______, _______, and HR
Only for patients who do not respond to _____
Treatment for Unstable Angina/NSTEMI
Nitro: 0.4 SL/spray - 3 doses max in 15 mins 5 mins apart
Ask if they have taken VIAGRA
Contraindicated in patient with VENTRICULAR MI
Morphine: When pain not relieved after NITRO
O2: For sats <90 or RESP DISTRESS
ASA: Given on PRESENTATION and continued; 80-160 CHEWED
BB: Reduced myocardial CONTRACTILITY
CCB: Decreases AFTERLOAD, CONTRACTILITY, and HR
Only for patients who do not respond to BB
STEMI: Thrombus _________ occludes CA
If quickly identified and treated, myocardial injury can be _______
Main treatment goal is to ________ _________ via _____ or _______
STEMI: Thrombus COMPLETELY occludes CA
If quickly identified and treated, myocardial injury can be REVERSED
Main treatment goal is to RESTORE FLOW via PCI or FIBRINOLYTICS
PCI: Angioplasty and Stenting
Target time ________ minutes after symptoms
PCI: Angioplasty and Stenting
Target time < 90 minutes after symptoms
Fibrinolytic: Considered when _____ is not an option
Coming from another hospital without cath lab and treatment exceeds _______ minutes
______ is most common. Contraindicated with ________ and _________
Fibrinolytic: Considered when PCI is not an option
Coming from another hospital without cath lab and treatment exceeds > 120 minutes
TNK is most common. Contraindicated with UNSTABLE ANGINA and NSTEMI
Fibrinolytic contraindications
Intracerebral hemorrhage
Known aneurysm
Uncontrolled HTN
Oral anti-coagulants
Recent surgery/internal bleeding
anything that might cause bleeding
What drug should be avoided for STEMI?
NSAIDs and COX-2
Patients who have survived a cardiac arrest and are comatose, should be assessed for _________, post PCI intervention
It can improve ______ outcome and survival post arrest
Patients who have survived a cardiac arrest and are comatose, should be assessed for TARGET TEMPERATURE MANAGEMENT, post PCI intervention
It can improve NEURO outcome and survival post-arrest
PCI: Use to _____ and ______ partially or completely occluded coronary vessels
A _____ inserted and mobilized to the identified blockage in the CA
Once at the blockage site, ________ and ________ can occur
Major complication of angioplasty: immediate _________ of vessel, but done with ________ to prevent this
PCI: Use to TREAT and EVALUATE partially or completely occluded coronary vessels
A CATHETER inserted and mobilized to the identified blockage in the CA
Once at the blockage site, ANGIOPLASTY and STENTING can occur
Major complication of angioplasty: immediate RE-STENOSIS of vessel, but done with STENTING to prevent this
Two Types of Stents:
Bare Metal Stent: Fewer _______ complications, but a higher incidence of _______ and rapid growth and spread of _______
Drug Eluting Stent: Have medication to inhibit ________ _________, decreased risk of ________, but increased risk of ______
Two Types of Stents:
Bare Metal Stent: Fewer THROMBOSIS complications, but a higher incidence of RE-STENOSIS and rapid growth and spread of CELLS
Drug Eluting Stent: Have medication to inhibit CELLULAR PROLIFERATION, decreased risk of RE-STENOSIS, but increased risk of THROMBOSIS
PCI: Radial vs Femoral Approach
Which one is the standard? Why (x2)
Which one is used for extensive PAD?
PCI: Radial vs Femoral Approach
Radial - less bleeding, fewer activity limitations
Femoral
PCI Nursing Management:
Monitor ____
Close ______ monitoring for reperfusion ______
Monitor _______ enzymes
Assess ______
PCI Nursing Management:
Monitor VS
Close TELEMETRY monitoring for reperfusion ARRHYTHMIAS
Monitor CARDIAC enzymes
Assess SITES, PERIPHERAL PULSES
Coronary Artery Bypass Grafting
Surgical procedure where ___________ from another area of the body are _______ and used to create a ____ route for the hearts blood supply
Used when patients have ____ or more ______ arteries and severe left CAD
____________ procedure
Coronary Artery Bypass Grafting
Surgical procedure where BLOOD VESSELS from another area of the body are REMOVED and used to create a NEW route for the hearts blood supply
Used when patients have 3 or more STENOTIC arteries and severe left CAD
EMERGENT RESCUE procedure
CABG Post-Op Nursing Management:
Assess ______
_______ pacing wires in-situ
Monitor ______ sites
CABG Post-Op Nursing Management:
Assess VS
EPICARDIAL pacing wires in-situ
Monitor GRAFT sites
What is heart failure?
An issue with the heart muscle - not pumping effectively
Impairs the ability of the ventricle to fill/eject blood
LS Heart Failure: Systolic Dysfunction
The inability of the ventricle to _______ properly - not ______ normally
Reduced _______
LS Heart Failure: Systolic Dysfunction
The inability of the ventricle to EMPTY properly - not CONTRACTING normally
Reduced EF
LS Heart Failure: Diastolic Dysfunction
The inability of the ventricle to ______ properly - not _______ normally
Increased _______
LS Heart Failure: Diastolic Dysfunction
The inability of the ventricle to FILL properly - not RELAXING normally
Increased EF
What type of symptoms do you have with LSHF?
Respiratory congestion - heart backing up into the lungs
SOB, orthopnea, crackles/wheezes, pink/frothy sputum, CP, confusion, S3/S4 sounds
Which side of the stethoscope is used to listen to heart and lung sounds?
Diaphragm
Where is the aortic sound heard?
R2ICS - sternal border
Where is the pulmonic sound heard?
L2ICS - sternal border
Where is the tricuspid sound heard?
L5ICS - sternal border
Where is the bicuspid sound heart?
L5ICS - mid-clavicular
Where is S1 heard?
Apex
Where is S2 heard?
Base
Which heart sounds best heard with bell?
S3/S4
S3
Ventricular gallop
An excessive amount of blood enters ventricle quickly - dilated LV (overly-compliant) - systolic
S4
Atrial gallop
Atria contract against stiff ventricle (non-compliant) - diastolic
Left ventricle HF can lead to which arrhythmia?
Atrial fibrillation
What is an LVAD?
A left ventricular assist device (LVAD) is implanted in the chest.
It helps pump blood from the lower left heart chamber (left ventricle) to the rest of the body
What is an RVAD?
An external right ventricular assist device (RVAD) helps support the right ventricle’s function and pump blood to the lungs
In patient’s with an LVAD/RVAD, patient’s do not have a ________ or ______
In patient’s with an LVAD/RVAD, patient’s do not have a PULSE or BP
How to check if LVAD/RVAD is working?
A stethoscope should be placed over the apex of the heart to listen for a humming sound
Absence of a humming sound indicates that the LVAD is not working
RS HF Manifestations
Weight gain
Edema
JVD
Ascites
Hepatomegaly
RSHF Causes
LSHF
Pulmonic Valve Stenosis
Last resort treatment for heart failure?
Heart transplant
Cardiomyopathy: _______ and/or _______ dysfunction resulting in ventricular ______ or _________
Cardiomyopathy: ELECTRICAL and/or MECHANICAL dysfunction resulting in ventricular DILATION or HYPERTROPHY
Cardiomyopathies:
Dilated
Hypertrophy
Restrictive
Cardiomyopathies:
Dilated - ventricular enlargement with thinning of the ventricular wall
Hypertrophy - thickening of the muscle wall
Restrictive - infiltration/fibrosis
Preload and Afterload:
Preload is the initial _______ of the cardiac myocytes (muscle cells) prior to contraction. It is related to ventricular ________.
Afterload is the force or load against which the heart has to _______ to eject the blood.
Preload is the initial STRETCHING of the cardiac myocytes (muscle cells) prior to contraction. It is related to ventricular FILLING.
Afterload is the force or load against which the heart has to CONTRACT to eject the blood.
Grading Valvular Disease:
Stages A-D
Stage D is when ________ develop
Grading Valvular Disease:
Stages A-D
Stage D is when SYMPTOMS develop
Aortic Stenosis:
_______ of the aortic valve
Causes increased ______ resulting in left ventricular ___________
Will hear a systolic ________
Diagnosed using an ___________
Presence of ________ determines if stenosis is ________ or not
Medical management does not alter ___________, and is only used for ___________ _______
Aortic Stenosis:
NARROWING of the aortic valve
Causes increased AFTERLOAD resulting in left ventricular HYPERTROPHY
Will hear a systolic MURMUR
Diagnosed using an ECHO
Presence of SYMPTOMS determines if stenosis is SEVERE or not
Medical management does not alter PROGRESSION, and is only used for SYMPTOM RELIEF
Which medication should be avoided in patients with aortic stenosis?
Which medications should be administered?
Beta-blockers - can worsen
Rate control (digoxin, amiodarone)
Diuretics
ACE inhibitors
Aortic Stenosis: Valve Replacement (SAVR vs TAVR)
Surgical Mechanical Valves: More _____, but require lifetime ________
Surgical Tissue Valves: Less ________, but no _________ required
SAVR requires open heart surgery and is not optimal for _____ _______ patients
TAVR: No open heart surgery, higher risk of _____, but more optimal for high-risk patients
Aortic Stenosis: Valve Replacement (SAVR vs TAVR)
Surgical Mechanical Valves: More DURABLE, but require lifetime ANTICOAGULATION
Surgical Tissue Valves: Less DURABLE, but no ANTICOAGULATION required
SAVR requires open heart surgery and is not optimal for HIGH-RISK patients
TAVR: No open heart surgery, higher risk of STROKE, but more optimal for high-risk patients
Aortic Regurgitation is when aortic valve does not ______ ________ and blood flows back into the _____
LV has to deal with normal amount of blood + extra blood that did not exit the heart = increased _______ = ventricle will ________ and ________ and overtime go into LV ___________
________ murmur
Treatment: CCB, BB, AVR
Aortic Regurgitation is when aortic valve does not CLOSE TIGHTLY and blood flows back into the LV
LV has to deal with normal amount of blood + extra blood that did not exit the heart = increased WORKLOAD = ventricle will HYPERTROPHY and DILATE and overtime go into LV HEART FAILURE
DIASTOLIC murmur
Treatment: CCB, BB, AVR
MITRAL STENOSIS:
Recurrent damage to the mitral valve causes blood flow across the MV to the ____ to be _____
This increases pressure in the ______ causing blood to back up into the _______ circulation
Chronic congestion will lead to ______ dilation which may lead to _______ __________
_________ murmur
Treatment: ______ control, _________ for a-fib, diuretics, and avoid strenuous activity
1) Percutaneous mitral balloon valvotomy
2) Commissurotomy
3) Mitral Valve Replacement
MITRAL STENOSIS:
Recurrent damage to the mitral valve causes blood flow across the MV to the LV to be REDUCED
This increases pressure in the ATRIA causing blood to back up into the PULMONARY circulation
Chronic congestion will lead to ATRIAL dilation which may lead to ATRIAL FIBRILLATION
DIASTOLIC murmur
Treatment: HR control, ANTICOAGULANTS for a-fib, diuretics, and avoid strenuous activity
1) Percutaneous mitral balloon valvotomy
2) Commissurotomy
3) Mitral Valve Replacement
Left Atrial Appendage:
Out-pouching of ____ that allows atria to dilate and become _____ if necessary
Blood can ____ in this area
Surgeons may do __________ to remove it and reduce the risk of stroke during mitral valve replacement
Left Atrial Appendage:
Out-pouching of LA that allows atria to dilate and become LARGER if necessary
Blood can CLOT in this area
Surgeons may do LIGATION to remove it and reduce risk of stroke during mitral valve replacement
Mitral Regurgitation:
The mitral valve does not close properly and blood backflows into ____
Overtime, LA ______ and ________
________ murmur
Treatment: Treat the _____ - stage ___ is the only stage where MVR is recommended
Mitral Regurgitation:
The mitral valve does not close properly and blood backflows into LA
Overtime, LA STRETCH and DILATE
SYSTOLIC murmur
Treatment: Treat the CAUSE - stage D is the only stage where MVR is recommended
PERICARDITIS:
Pericardium is a sac containing the heart and roots of great vessels
Pericarditis is _____ of this sac and causes ++ ______ _________
By definition, anyone who receives ________ _________ _______ will have pericarditis
Most common causes: recent ___ or _______ failure 2* to uremic accumulation
PERICARDITIS:
Pericardium is a sac containing the heart and roots of great vessels
Pericarditis is INFLAMMATION of this sac and causes ++ CHEST PAIN
By definition, anyone who receives OPEN HEART SURGERY will have pericarditis
Most common causes: recent MI or RENAL failure 2* to uremic accumulation
Pericarditis Assessment:
Chief complaint: ______ _____
Pain is _____, sharp and positional
Increases with _______ breath
Lying on _____ or ____ will also increase pain
Patient may also be ______ and have shallowing breathing and patients are prone to _______-arrhythmias
Pericardial friction rub is present when patient is lying on ______ side. Have patient take a deep breath and hold. If still hear the rub, it is ______. If it goes away, it is ________.
Pericarditis Assessment:
Chief complaint: CHEST PAIN
Pain is PLEURITIC, sharp and positional
Increases with DEEP breath
Lying on BACK or LEFT SIDE will also increase pain
Patient may also be TACHYPNEIC and have shallowing breathing and patients are prone to TACHY-arrhythmias
Pericardial friction rub is present when patient is lying on LEFT side. Have patient take a deep breath and hold. If still hear the rub, it is PERICARDIAL. If it goes away, it is PLEURAL.
What medication to use with caution with pericarditis?
Anticoagulants - may cause more bleeding which may lead to cardiac tamponade (pericardium is inflamed and raw)
MYOCARDITIS:
Inflammation of the __________
Most often caused by ________ infection
Usually, resolves ________ _______ _______, but limit _____ to decrease damage as well as reduce ______ intake to decrease fluid retention
MYOCARDITIS:
Inflammation of the MYOCARDIUM
Most often caused by VIRAL infection
Usually, resolves ON ITS OWN, but limit ACTIVITY to decrease damage as well as reduce SALT intake to decrease fluid retention
ENDOCARDITIS:
Inflammation of the ______ (______ of the heart), usually on the heart ______ - which often leads to ______ vegetation. These can break free and ______ to distal organs.
Infective endocarditis is usually caused by _____ in the _____ or _____ procedures. A ______ can be used to diagnose.
Patients may present with:
- Hematuria 2* _______________
- Osler nodes
- Janeway lesions
- Splinter hemorrhages
ENDOCARDITIS:
Inflammation of the ENDOCARDIUM (LINING of the heart), usually on the heart VALVES - which often leads to VALVE vegetation. These can break free and EMBOLIZE to distal organs.
Infective endocarditis is usually caused by BACTERIA in the BLOOD or DENTAL procedures. A TTE can be used to diagnose.
Patients may present with:
- Hematuria 2* GLOMERULARNEPHRITIS
- Osler nodes
- Janeway lesions
- Splinter hemorrhages
MAP Calculation:
SBP + (2DBP) / 3
Normal: _____ to _____ mmHg
Tells us how well organs are being ________
MAP Calculation:
SBP + (2DBP) / 3
Normal: 70 to 100 mmHg
Tells us how well the body is being PERFUSED
How might a ventricular-paced rhythm affect CO?
No atrial kick = decreased CO
